Medical liability concerns drive hospital admission decisions

Medical liability is a key reason physicians admit more emergency department patients and discharge them less, say two studies in the October Annals of Emergency Medicine.

In one study, a survey of 849 emergency physicians and patients in two inner-city emergency departments found that 11% of physicians reported "medico-legal" concerns as a primary driver for admitting patients with potential acute coronary syndrome (www.annemergmed.com/article/S0196-0644%2811%2900824-9/fulltext).

In another study, researchers compared admission rates for congestive heart failure patients in 27 emergency departments in New Jersey and New York between 1996 and 2010. The percentage of such patients discharged from EDs dropped from 24% to 9%.

The findings show that doctors consider factors other than patients’ health when making admission choices, said co-author of the coronary study David Newman, MD, an emergency physician and director of clinical research in the Dept. of Emergency Medicine at Mount Sinai School of Medicine in New York.

"Most physicians know we consistently overestimate risk in our discussions with patients. The question is, why? Most physicians would say medico-legal fears are a big reason why," he said.

Medical liability worries are not the only pressure leading to more patient admissions. Economics, hospital crowding and time constraints also probably play a role in such decisions, Dr. Newman said.

Discharge decisions

Fear of being sued contributes to doctors keeping patients in the hospital longer, said New Jersey emergency physician John Allegra, MD, co-author of the heart failure study.

"We’re ordering more tests and becoming more reluctant to send patients home in order to pick the one in 100 or one in 1,000 who might have a serious adverse event," he said.

Trying to achieve a "zero error rate" is causing stress on the health care system and creating significant medical costs, he added.

Dr. Newman said physician concerns about medical liability will continue to grow until nationwide tort reforms are made.

"The lack of action taken to repair our broken malpractice system has led to an increase in fear," he said. "The longer we leave this problem unaddressed, the more legal-medico fears will drive decisions."